Addressing the effectiveness of health literacy programs within the Gulf Corporation Council: an integrative review

Abstract Health literacy is an increasingly required need to help individuals, families and communities manage their health and health conditions. It is linked with better self-adherence to treatments, use of resources, access to care and overall reduced costs in healthcare. In the Gulf Cooperation Council (GCC), which comprises Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and the United Arab Emirates, various health literacy programs are implemented across states to address people’s unique and complex healthcare needs. This article aims to examine the current literature and assess the factors that influence the outcomes of health literacy programs within the GCC. An integrative review methodology has been conducted to pursue a comprehensive understanding of health literacy interventions in the GCC. This investigative approach was shaped by Whittemore and Knafl’s framework (2005), which includes problem identification, literature search, data evaluation, data analysis and presentation. The literature on the effectiveness of health literacy interventions and the factors that shape them are notably limited worldwide and within the GCC region. This integrative review addresses this knowledge gap and highlights the significance of key themes such as sessions, evaluation and improvement in shaping health literacy outcomes within the GCC region. Through this integrative review, the three main themes of sessions, evaluation and improvement were identified as influencing the outcomes of health literacy programs within the GCC.


INTRODUCTION
Health literacy is required to help individuals, families and communities manage their health and health conditions (Elbashir et al., 2023;Johnson et al., 2022).Higher health literacy is linked with better selfadherence to treatments, use of resources, access to care and overall reduced costs in healthcare (Johnson et al., 2022).However, health literacy skills globally vary across regions, with reported ranges of 7-47% in developed nations (Johnson et al., 2022).Health literacy programs have emerged as strategies for enhancing skills and addressing the needs of patients, individuals and populations to minimize gaps.This strategy helps individuals and groups navigate complex healthcare systems and aids in positioning healthcare providers to be better engaged in providing patient-centred care, especially in managing disease and illness (Elmer et al., 2017).Health literacy programs address different topics and demographics and are tailored to accommodate the diverse needs of their populations.Knowing health literacy programs may vary across subjects, populations and regions, each needs to evaluate factors that influence its efficacy and outcomes (Elmer et al., 2017).
In the Gulf Cooperation Council (GCC), which comprises Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and the United Arab Emirates, various health literacy programs are implemented across countries to address the unique and complex healthcare needs of people (Elbashir et al., 2023;Johnson et al., 2022;Khoja et al., 2017).While the correlation between health literacy and health outcomes is well known, there is less understanding of the efficacy of those interventions and the factors that may influence them (Elmer et al., 2017;Johnson et al., 2022).Understanding factors that influence the effectiveness of health literacy interventions is necessary to serve as a tool or model when developing future interventions in the region.This article aims to examine the current literature and assess the factors that influence the outcomes of health literacy programs within the GCC.

METHOD
An integrative review can provide an array of detail to problems that may be complex, especially within the healthcare milieu.Therefore, an integrative review was chosen to investigate the phenomenon in question to help elucidate information related to health literacy interventions within the GCC.This integrative review was guided by Whittemore and Knafl's (2005) framework, which includes problem identification, literature search, data evaluation, data analysis and presentation.

Problem identification
The first step of Whittemore and Knafl's (2005) framework for an integrative review is problem identification.With the initial scoping of the literature and discussion among the team members, we identified that it is essential to conduct a comprehensive search of the literature to understand various interventions and assess the factors affecting the outcomes of health literacy programs.Having clearly identified these problems, we developed our literature search and screening strategies, followed by appropriate analysis and reporting.

Literature search
First, we identified the relevant databases that needed to be searched to ensure we did not miss any potentially eligible studies.We reviewed the other health literacy-related reviews to identify the relevant databases, including academic and grey literature.We also consulted with a systematic review expert to finalize the databases.
In the next step, we developed a search strategy to draw all the relevant articles from the databases.We identified the terms that bear similar meanings or are used as indexing terms (such as Medical Subject Headings) for different databases based on the three key terms 'health literacy', 'Gulf Cooperation Council' and 'intervention'.After that, we developed the inclusion and exclusion criteria aligned with the study's objectives to screen the articles abstracted from all the databases.
We identified 1345 articles from the academic databases and 965 from the grey literature, resulting in 2310 articles.After duplicate removal, we had 1975 articles to screen.Two independent reviewers (M.R. and J.J.) first excluded the articles that did not meet the inclusion criteria based on the titles and abstracts of the articles.We used Rayyan QCRI software to facilitate this level of screening.The articles deemed eligible or inconclusive to exclude based on title/ abstract did not move to the next screening level (n = 94).This time, both reviewers reviewed the articles' full text and included only those meeting the inclusion criteria.In case of disagreement between the reviewers, both discussed with a third reviewer (N.C. or T.C.T.) and reached a consensus.Finally, we had 10 articles to analyse.See Figure 1 for flow chart and process.

Data evaluation and extraction
Data evaluation was deemed unnecessary in this study as, according to our employed framework by Whittemore and Knafl (2005), evaluating the studies in an integrative review is not essential given the complex methodologies and findings drawn in this type of review.Also, our objective is broad and includes  a summarization of a range of findings; thus, unlike a systematic review, it is not focused on synthesizing answers to a specific question from findings from studies with the same or related questions.Therefore, once we finalized the eligible articles, we moved to data synthesis directly following the data extraction.We used a predetermined data extraction template at this level.

Data synthesis and presentation of the findings
We have coded the texts of the eligible studies using an open coding method.We looked for any information on the outcomes of health literacy assessments.Additionally, study characteristics such as location, sample size and others were collated for review.Once coding was complete, we identified the similar and contrasting codes to detect any emerging pattern.With the iterative process of reviewing the codes and the texts, we identified the eminent themes and provided a narrative description.

Characteristics of the studies
This integrative review examines 10 research articles published between 2010 and 2022.These studies were conducted in the GCC region: Qatar (n = 1), the United Arab Emirates (n = 1) and the Kingdom of Saudi Arabia (n = 8).Articles are primary resources that consist of quantitative studies.There was one cross-sectional, one clustered experimental, one retrospective observational cohort pretest-posttest experimental, three quasi-experimental, two randomized trials and one cluster randomized control.
The cross-sectional study by Halawany et al. (2018) examined the effectiveness of oral health intervention in improving knowledge and self-reported oral health behaviour among primary school female children.Ba-Essa et al. (2015) assessed the impact of intensified self-monitoring of blood glucose with education on diabetes mellitus patients.Mahmoud et al. (2018) assessed the effects of a psychoeducational intervention program on an indicator of glycaemic control, and HR-QOL (health-related quality of life) was examined in type 2 diabetic patients.Sani et al. (2018) tested the effectiveness of the Jizan Integrated Lifestyle Education (JILSE) program on glycaemic control of diabetic patients.A cluster randomized trial by Alzaher et al. (2018) consisted of delivering a hand hygiene workshop intervention and reported its impact on reducing school children's absenteeism due to upper respiratory tract infection.Mohammed et al. (2016) examined the efficacy of a smoking prevention program on smokingrelated cognitions and behaviour for male adolescents.A retrospective observational cohort study by Rahhal et al., (2021) compared the impact of clinical pharmacists and other healthcare providers' education on patients' adherence to post-percutaneous coronary intervention medication.Rabbani et al., (2019) explored the effectiveness of a community-based educational intervention in promoting breast cancer screening and health behaviour changes.Bakarman et al. (2019) conducted a randomized interventional study to assess healthrelated quality of life among haemodialysis patients.Sharaf's (2010) study assessed the impact of health education on the knowledge, behaviour and compliance of patients with hypertension, type 2 diabetes mellitus and coronary artery disease (Table 1).Sharaf's (2010) study assessed the impact of health education on the knowledge, behaviour and compliance of patients with hypertension, type 2 diabetes mellitus and coronary artery disease.See Table 1 for all study characteristices and Table 2 for all health literacy initiavites.

FINDINGS
This integrative review aimed to assess the factors influencing the outcomes of health literacy programs within the GCC countries.Three main themes were identified while reviewing information in the literature: sessions, evaluation and improvement.

Sessions
Educational programs that enhance health literacy in the GCC were tailored in multiple sessions.These sessions were delivered individually or in a group manner utilizing strategies such as didactic presentations, peer support and interactive discussions, among others.Depending on the program, most sessions lasted from about 30 min to 1 h over weeks to months.It is important to highlight that these sessions were age-based, provided supportive materials to the clients and were culturally oriented.
The participants' ages in these health literacy educational sessions ranged from 6 to 75.These sessions were developed with the participants' age groups in mind to achieve the main objective of enhancing health literacy.For instance, Halawany and colleagues (2018) used animated videos to improve 6-year-old students' knowledge and oral hygiene behaviour.Similarly, Alzaher et al.'s (2018) study used puzzle games and cartoon princess pictures to teach schoolgirls the importance of hand washing.Video peer sessions led by participants of the same age group were another method Mohammed et al. (2016) used to teach male adolescents about smoking prevention.In contrast, sessions designed for adult participants were based on didactic lecturing and discussions (Bakarman et al., 2019;Rahhal et al., 2021).
In addition to age, these sessions were equipped with various educational materials distributed during or after the sessions concluded.Alzaher et al. (2018) and Ba-Essa et al. (2015) provided participants with posters, leaflets, transcribed pamphlets and video films as audiovisual aids to remind them of the given information.
In the GCC region, cultural beliefs and values are highly associated with compliance with prescribed regimens.Therefore, when developing these educational sessions, developers utilized as many culturally appropriate resources as possible.In Sharaf's (2010) study, investigators noted that smoking was becoming a part of the culture in Saudi Arabia.Hence, this was considered when assessing the impact of health education on the health knowledge and behaviour of patients with chronic diseases.Also, in the study by Mohammed et al. (2016), researchers adopted a Dutch smoking prevention program but adapted it to meet the cultural norms consistent with Saudi culture.The cultural aspect was maintained constantly when these educational sessions were developed by Alzaher et al. (2018), and the suitability of the sessions to the local cultural conditions was tested by Sani et al. (2018) before delivering their education.In short, the GCC has a unique culture that impacts health decisions; hence, researchers maintained this aspect when considering any educational session they delivered to clients.

Evaluation
Evaluation is required when delivering health literacy programs to assess the attendees' knowledge and understanding of desired outcomes and program effectiveness.Investigators who conducted these programs from a health literacy lens followed up with their participants, while others compared pre-and post-interventions to check compliance.Alzaher et al. (2018) followed up with participants after 5 weeks of attending the diabetic management program to examine whether participants maintained the suggested lifestyle changes.These authors found that this period was not too short to assess compliance properly: the same was noted by Bakarman et al., 2019.Other investigators followed up with participants after 6 months of interventions.Mohammed et al. (2016) examined the effects of interventions on socio-cognitive factors and behavioural effects, which was congruent with Sharaf's (2010) study, which also noted that with more time, there is more compliance with diabetic regimens.According to Ba-Essa et al.'s (2015) study, which looked at glucose self-monitoring education in diabetes mellitus patients in Saudi Arabia, the authors conducted regular monthly follow-ups of patients with diabetes for 4 months straight to ensure compliance was maintained.Baseline knowledge (pre-test) regarding BC was assessed using the study questionnaire.
-Educational intervention in BC was administered.
-The impact of educational intervention was evaluated with a post-test questionnaire after 4 weeks.
-End-line survey conducted at the end of the intervention to evaluate the educational sessions.
In Pre-and post-intervention assessment is another form of evaluation to monitor the effectiveness of health literacy programs.Investigators of these studies used surveys to compare pre-and post-effectiveness in their participants (Ba-Essa et al., 2015;Mahmoud et al., 2018).Halawany and colleagues (2018) distributed questionnaires for pre-diabetic training 6 weeks after post-delivering their program to evaluate the level of improvement of knowledge and self-reported behaviour of their participants in oral health.Comparing pre-and post-surveys was noted to be a common strategy in assessing the effectiveness of health literacy in diabetic management programs (e.g.Bakarman et al., 2019;;Sani et al., 2018).

Improvement
Examining the effectiveness of health literacy programs can increase the knowledge enhancement of recipients, modify behaviours, improve compliance with comorbidity regimens and improve health-related quality of life.Increased knowledge of participants' health literacy levels is evidence of the effectiveness of these programs in the GCC.In a study by Rabbani et al., (2019), participants showed statistically significant improvement in their knowledge, and interventions were more beneficial to the women without formal education (p = 0.001).Also, participants enrolled in diabetes health literacy programs significantly increased their knowledge (Ba-Essa et al., 2015;Mahmoud et al., 2018;Sani et al., 2018).Increased knowledge demonstrated by participants is a key factor influencing the effectiveness of health literacy programs (p = 0.001).
In addition to knowledge, behavioural change is another component that measures the success of these programs.Investigators such as Halawany et al. (2018) aimed to examine self-reported oral health behaviour among schoolchildren and noted a 25% significant improvement in their health-related behavioural interventions.Like Ba-Essa et al.'s (2015) study, they found more significant improvement in the attitude and behaviour of participants in the experimental group compared to the control group.Moreover, Sharaf's (2010) study assessed the knowledge and behaviour of patients with comorbidities (n − 1011).He found significant improvements in smoking, diet and exercise habits in the study participants once the program was delivered.On the other hand, smoking habits and physical exercise were not statistically significant (p > 0.05) in a similar study conducted by Sani et al. (2018).Collectively, behavioural change is a common indicator in these health literacy interventions.
Patients with comorbidity are anticipated to benefit from health literacy programs, thereby modifying their health decisions and complying with recommended regimens.It was noted that patient compliance with the comorbidity regimen is a valued parameter in improving the effectiveness of health literacy programs.In the study by Rahhal et al., (2021), investigators assessed compliance with the regimen of adult patients (n = 1334) who underwent percutaneous coronary intervention (PCI) and received clinical pharmacists' educational interventions during discharge from the hospital.These investigators found significant adherence to post-PCI medication.Another study concluded that health education for participants with chronic diseases significantly improved compliance with their primary doctors' advice regarding smoking, diet and exercise (Sharaf, 2010).
Besides compliance with comorbidity regimens, enhancing health-related quality of life (HR-QOL) is another desirable goal noted by health literacy programs.According to Bakarman et al. (2019) study, an overall increase in the scores of HR-QOL for patients with haemodialysis significantly improved after educational interventions compared to those in the control group.It was also noted that there was a significant improvement in the mean scores of HR-QOL scales for patients with type 2 diabetes mellitus in Mahmoud et al. (2018) study. Ba-Essa et al. (2015) study worked to ensure their health literacy program was aimed at improving overall health status and quality of life for patients with type 1 and 2 diabetes mellitus.

DISCUSSION
There is scant literature about the efficacy of health literacy interventions worldwide and the factors that influence them, specifically within the GCC region.This integrative review closes this gap and identifies the themes of sessions, evaluation and improvement as factors influencing health literacy outcomes in the GCC countries.
Under the session's theme, interventions associated with increased health literacy were provided using multiple sessions tailored to age and culture.A systematic review by Walters et al. (2020) of 22 studies similarly found that the majority of health literacy interventions were provided in multiple sessions and also had variations in session frequency and duration, with session lengths ranging from 40 min to all day at different frequencies (e.g.twice a week, weekly, every 2 weeks and monthly) for a total duration of 2 weeks to 12 months (Walters et al., 2020).Mirroring the findings from this review, interventions were delivered individually or in groups, with small group sessions being the more common delivery method (Walters et al., 2020).For adults, various strategies were likewise used, including educational sessions, text or social media messages, leaflets, psychosocial support, counselling and animation videos (Walters et al., 2020).Interventions incorporated into the school setting illustrate a crucial age-based approach to promoting health literacy among young people (World Health Organization, 2017).Effective intervention strategies used with children and adolescents utilize a practical, 'hands-on' approach, such as mindfulness or cooking activities, performing skits, using social media and incorporating peer models or peer support.Like the peer-led smoking prevention groups in the Mohammed et al. (2016) study, they are holistic by engaging schools, families and communities (Pleasant et al., 2019;Smith et al., 2021).The cultural adaptations to health education programs described above are supported by multiple studies illustrating how culturally sensitive considerations help to promote health literacy (Bader et al., 2022;Li et al., 2023;Tucker et al., 2019).Such considerations include having educational materials available in the relevant languages (Bader et al., 2022;Li et al., 2023) and in audiovisual format (Li et al., 2023) and incorporating influential community figures, such as religious leaders (Tucker et al., 2019), into the delivery of health literacy interventions.Further research is needed to explore any difference in efficacy between single vs. multiple-session health intervention delivery and associated outcomes.
The evaluation of health literacy programs is important to determine the effectiveness of the implemented interventions.This integrative review found that evaluation of programs in the GCC occurred through follow-up with study participants to assess for compliance and through pre-and post-intervention surveys to assess participant knowledge and behaviour.Such evaluation measures (follow-up for compliance and prepost-intervention assessment) can provide evidence linking a specific intervention with health literacy outcomes (e.g.increased or decreased) if any change occurs.Follow-up occurred several (4-5) months after the intervention for the studies in this review, whereas follow-up in the Bader et al. (2022) review ranged from 2 weeks to 1 year.Nutbeam et al. (2018) reviewed the literature and found six studies that utilized a pre-post-study design to assess health literacy interventions, further supporting the importance of evaluation.Comparison assessments were also made in the Walters et al. (2020) systematic review, where all 22 of the included studies contained a pre-post measure of health literacy based on subjective self-reports, objective measures or validated instruments, such as the newest vital sign (NVS), test of functional health literacy in adults / short test of functional health literacy in adults (TOFHLA/STOFHLA) and the Health Literacy Questionnaire (HLQ).Post-assessment occurred as early as the same day of the intervention up through 12 months following the intervention (Walters et al., 2020).
The final improvement theme can be demonstrated through increased knowledge, behaviour change, treatment regimen compliance and health-related quality of life improvement.Similar indicators of improvement are evident in numerous studies.In the systematic review by Walters et al. (2020), 15 of the 22 identified studies (n = 10 181) demonstrated improvements in health literacy associated with implemented interventions, with a statistically significant increase in 12 studies.Health literacy outcome measures were not always clearly defined and ranged from subjective selfreported information to objective data and validated tools.Greater standardization of outcome measures will help optimize health literacy assessment (Bader et al., 2022).Seven out of eight studies with behavioural measures demonstrated significant improvements in behavioural outcomes following health interventions.The behavioural effects included smoking prevention, nutrition, physical activity, cancer screening, lifestyle, self-care and cardiovascular health (Walters et al., 2020).Regarding compliance with comorbidity regimens, an educational intervention consisting of three group workshops significantly affected health literacy, self-efficacy and self-care behaviours for patients with heart failure both at the time of the intervention and during follow-up in 3 months (Walters et al., 2020).Stellefson et al. (2019) found increased health-related quality-of-life scores significantly associated with higher health literacy levels in individuals diagnosed with chronic obstructive pulmonary disease.

LIMITATIONS
Limitations of this integrative review highlight the need for further health literacy studies in all regions of the GCC.Most studies included in the review were from Saudi Arabia, with no study included in the review from Bahrain or Oman.Further studies assessing health literacy interventions directly are needed in the GCC region.

CONCLUSION
The efficacy and outcomes of health literacy program interventions must be evaluated within the context of the region and population.Through this integrative review, the three main themes of sessions, evaluation and improvement were identified as influencing the outcomes of health literacy programs within the GCC.Ten studies were assessed for characteristics, study findings and evaluation of efficacy.These studies deployed various interventions and included the development of culturally appropriate materials or modifying adopted programs.Identifying these core themes can serve as a model for developing future health literacy interventions in the GCC region.

Table 1 .
ContinuedHealth literacy programs within the Gulf Corporation Council

Table 2 :
Description of health literacy initiatives in included studies